HealthJune 12, 2018

Lightening the burden of managing chronic disease

“My dad and I talk regularly about his diabetes, how he’s feeling and what weekly steps he’s taking. We’ve also found that verbalizing him taking action to make follow-up appointments helps him actually get there. Voicing goals after a diagnosis, especially to those that care about you, can be the key to keeping you on the right track.”

Like Kelly Hawthorne’s dad, many experience a diabetes diagnosis and the daily challenges that come along with managing this condition.

In 2017, some 30.3 million Americans –about 9.4% of the US population- were estimated to have diabetes, the CDC reports, and 84.1 million US adults aged 18 years or older had prediabetes. Because it’s so widespread and difficult to manage, the CDC even started a dedicated Twitter handle for “ALL things #Diabetes” back in 2015, and there’s an abundance of “healthy living” publications and patient community platforms that focus on diabetes.

But not all patients have a strong support network like Kelly’s dad. And sometimes, family support is not enough to do the right thing to keep diabetes’ complications at bay.

Diabetes is one of several chronic diseases that present major challenges to health care systems. In the US:

  • 1 in 2 adults have one or more chronic health conditions
  • 1 in 4 adults have two or more chronic health conditions
  • 7 of the top 10 causes of death in 2014 were due to chronic disease

Leading chronic illnesses also include hypertension (75 million Americans), asthma and COPD (36 million), and heart disease (28 million).

Direct medical costs to treat diabetes totaled $237 billion in 2017, up from $176 billion in 2012, the American Diabetes Association estimated in March 2018. Average per patient cost was $16,752, of which about $9,601 is attributed to diabetes. Most of the cost for diabetes, 66%, is paid by government insurance, including Medicare, Medicaid, and the military.

High-risk patients with chronic illnesses consume a large proportion of total health spending. Many people who are not yet in that category can be considered rising-risk patients – a large but sometimes invisible population who are hard to manage.

Those rising-risk patients have three key characteristics:

  1. The patient has 1 to 2 well-managed chronic diseases
  2. Symptoms are not severe and can be ignored
  3. The patient has co-occurring psychosocial risk factors

Providers and health insurers can help slow down the progression of rising-risk patients to the high-risk, high-expense zone. Patients’ health behavior and understanding of the disease can also tip the balance in the right direction.

Again, consider diabetes: The complications from diabetes can be serious, costly, and deadly. They include heart disease, stroke, kidney damage (chronic kidney disease and kidney failure), blindness, and amputations of the legs and feet.

People who haven’t managed their diabetes or who have had diabetes for a longer time are more likely to suffer these complications. Those who are educated in managing their blood sugar levels and who participate in preventive care may be able to postpone the onset of some of these complications. Preventive care for diabetes would include having annual examinations of the feet and eyes, and attending diabetes self-management classes.

The opportunity to prevent and manage chronic disease is large, yet not fully realized by patients or health care providers. It can be expensive and time-consuming to try to teach patients what they should do. And it requires follow-up to make sure patients understand their instructions and schedule the recommended appointments.

Technology-enabled platforms that let providers reach out to their patient population without expending huge amounts of time or personnel resources can help relieve these cost pressures. Such platforms can also lead to more favorable outcomes among a patient population. By freeing up staff to interact with more patients, these technologies may also allow providers to schedule more patient visits and grow revenue at the institution.

Examples of Emmi programs addressing chronic disease issues:


  • Diabetes: Eye exam
  • Diabetes alert – Overdue for A1c
  • Prediabetes


  • Asthma action plans
  • Asthma peak flow meter
  • COPD: What patients can do

Cardiac care

  • Peripheral artery disease
  • Heart disease: Lifestyle changes
  • Heart failure – Daily weight


  • Flu vaccine reminder
  • Medicare annual wellness visit
  • Colonoscopy – Why get one?

Contact us to learn about how EmmiEngage® and EmmiPrevent® programs can help support your chronic care management efforts.


Engage every patient in their journey

Easy-to-use interactive programs, featuring conversational language and relatable examples, help you foster connections and extend your team’s reach beyond healthcare settings.